Medicare can provide coverage for substance abuse treatment. Many people suffer without treatment because they’re unaware of available options.
The use of drugs can impair the capability to manage life; this is a substance abuse disorder. Work, school, home, health, problems, or disabilities are often difficult to manage.
Medicare pays for many substance abuse programs. Including inpatient rehab, outpatient counseling, and medication.
You may have out-of-pocket costs such as copays and deductibles. The price of a program depends on where you get treatment and your insurance.
Does Medicare Cover Substance Abuse Treatment
Medicare covers substance abuse treatment when necessary. You must get substance abuse services from a doctor. Coverage is different for inpatient services than for outpatient programs.
Outpatient treatment allows you to continue living at home while in rehab. Services include counseling, doctor visits, and prescription medications.
For any outpatient program, Part B covers doctor visits, including counseling. Part B pays 80% of your costs after you have met the annual deductible. A supplement may pay the other 20%.
Another, more intensive, outpatient option is a partial hospitalization program. To qualify, the doctor must certify that you would otherwise have to be in an inpatient program.
Inpatient treatment involves admission to a facility for 30, 60, or 90 days. Part A‘s benefits cover inpatient rehab, doctors, counseling, and drugs at the facility.
Once you have paid your Part A deductible, Medicare covers 100% of your costs for the first 60 days. After that, you pay a daily coinsurance charge.
Medicare Part A Coverage for Substance Abuse
Part A may cover the cost of the stay for an inpatient facility. Your doctor must write a recommendation for treatment and believe it to be necessary.
You must pay Part A deductibles, copayments, or coinsurance amounts that may apply. Also, any inpatient medications for treatment may have coverage by Part A.
Also, Medicare may cover the Partial Hospitalization Program (PHP) for substance abuse treatment. Your doctor must certify that you need twenty hours or more of therapeutic services weekly.
Then, your doctor must submit a plan for treatment and recertify your needs.
Tip: Part A pays for the Medications you get as part of inpatient treatment.
Medicare Part B and Substance Abuse Coverage
Outpatient counseling falls under Part B. Counseling for substance abuse, and mental illnesses have coverage. Services must come from a mental health professional.
Once you meet your Part B deductible, Medicare may pay for 80% of allowable charges for counseling.
Medicare requires counseling to be in the doctor’s office, a hospital outpatient setting, or a mental health center. You pay the remaining 20%.
Hospital-outpatient settings may have a cost when getting treatment. Also, Part B covers medicines that are given to you by a doctor, meaning they can’t be self-administered.
Part B outpatient drugs that treat substance abuse and addiction have different criteria. Ask your doctor any questions about treatment.
Tip: Part B provides coverage for some medications given by an outpatient facility.
Medicare Advantage Coverage for Substance Abuse
Those with Medicare Advantage coverage have access to substance abuse treatment. But, it’s essential to use an in-network doctor. Otherwise, you pay ALL costs.
Contact your health plan to find an in-network specialist. You can also call an agent at the number above to discuss plan options.
Tip: You let professionals help you with your healthcare, you should have a professional help you with your insurance too!
Part D and Substance Abuse Medications
Prescriptions are only covered if you have a separate Part D plan. Part D covers prescription substance abuse medications that you take at home.
Each Part D plan has a schedule of covered drugs and their cost. Coverage for a specific medication depends on your policy and whether you use one of the plan’s preferred pharmacies.
Tip: Never judge a policy by the premium; the TOTAL annual cost is the most relevant price. You must understand the out of pocket expenses alongside the premium.
Medicare Reimbursement for Substance Abuse Treatment
Before 2014, Part B paid a different rate for mental health services than for other types of claims. Since 2014, Medicare reimbursed psychiatric and substance abuse doctors 80% of the approved price for services.
You can expect to pay 20% of the Medicare rate for outpatient treatment. Out of pocket costs may be different if you have a Supplement or Advantage plan.
Medicare Admissions Criteria for Inpatient Substance Abuse Treatment
Medicare pays for inpatient substance abuse treatment if it is reasonable, and your doctor determines it is necessary. “Necessary” means care will diagnose or treat a condition.
Also, the therapy must meet accepted medical standards. Inpatient treatment may require prior authorization.
Medicare Coverage for Substance Abuse FAQ’s
Does Medicare Cover Drug Rehab?
Medicare’s substance abuse treatment coverage includes rehab for all types of drug addiction. Coverage extends to those with illegal drug addiction and addiction to prescription drugs.
Does Medicare Cover Alcohol Rehab?
Medicare covers treatment for alcohol misuse and rehab. Including inpatient care, outpatient counseling, and drugs to help you stop drinking.
The rules for alcohol rehab coverage are the same as for any other type of substance abuse.
How Long Does Medicare Pay for Rehab?
Part A pays the full cost of 60 days of inpatient rehab in a semi-private room. For days 61 to 90, it costs you $352 coinsurance each day.
After the 90th day, the coinsurance amount doubles, and you begin using “lifetime reserve days.” Medicare only allows 60 of these during your lifetime.
If you’ve been an inpatient for over 90 days and you don’t have lifetime reserve days, Medicare won’t pay for care. But, a Supplement plan can extend the number of days you have hospitalization coverage.
If you get inpatient care at a psychiatric hospital, Medicare covers 190 days of lifetime care. The limit on lifetime days is a problem if you need intensive mental health services or suffer a relapse.
But the limitation doesn’t apply to care in a general hospital. For most people in rehab, an inpatient stay is the beginning of the journey.
After discharge, Part B will continue to pay for counseling and medical care needed to stay on track.
Does Medicare Cover Opioid Treatment?
As of 2018, an estimated 300,000 Medicare patients had an opioid addiction. Medicare covers treatment for opioid addiction in a hospital or doctor’s office in the same as other treatments.
As of 2020, Part B coverage extends to opioid treatment programs and methadone clinics that enroll in Medicare. Coverage includes telehealth services as well as in-person services.
Does Medicare Cover Methadone Treatment?
Methadone is the oldest and best-known opioid treatment. If administered to an inpatient at a hospital, Part A covers methadone.
For people who are not inpatients, methadone is a highly-controlled prescription drug that you can’t get at a regular pharmacy. Patients must go to an opioid treatment center for daily doses of methadone.
In 2020, Medicare covers methadone and other opioid treatment services that enroll in Medicare.
Does Medicare Advantage cover methadone?
Yes, Medicare Advantage covers methadone, whether inpatient or outpatient. Advantage plans must offer the same benefits as Medicare.
Yet, there is a network of doctors and hospitals. You need to use a facility in your plan’s network to get the most benefit.
Also, deductibles and copays vary by policy.
Does Medicare Cover Suboxone?
Suboxone is a prescription that treats addiction to heroin and prescription opioids. Unlike methadone, you can get Suboxone at a regular pharmacy.
Most Part D plans cover Suboxone, but your copay may vary depending on your policy and the pharmacy you use.
Does Medicare Cover Counseling?
Part A covers substance abuse counseling while you are an inpatient. Part B includes substance abuse counseling when a mental health doctor provides care.
Mental health professionals include psychiatrists, psychologists, and licensed clinical social workers. Medicare pays for individual or group sessions.
But it doesn’t pay for support groups, peer counseling, or other informal counseling. Beginning in 2020, Medicare will also pay for telehealth counseling as part of an opioid treatment program.
Does Medicare Cover Addiction Treatment?
Overcoming a severe addiction may mean months in inpatient rehab and years of outpatient therapy. Often, people with addictions struggle with mental health issues.
Medicare covers addiction treatment, but you may pay deductibles, copays, and coinsurance. Those with a Medigap plan will pay less out of pocket than those with Medicare.
Does Medicare Part D Cover Methadone 5mg Tablets?
Doctors prescribe methadone 5 mg tablets for severe pain. Part D covers methadone for pain, but your copay depends on your plan.
Part D doesn’t cover methadone for substance abuse treatment, but Part B might.
Medicare Supplement Coverage for Substance Abuse Treatment
Substance abuse treatment can be a long and challenging road, and the costs can add up. A Supplement plan can make these costs manageable by picking up the Part A deductible.
Further, Medigap covers the daily copays on long-term hospital stays and the coinsurance for Part B. Our mission is to help you get the best insurance for the best price.
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